ObjectiveTo describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements. MethodsWe designed a ...formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application. FindingsResearchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers. ConclusionLessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains.
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CEKLJ, DOBA, IZUM, KILJ, NUK, ODKLJ, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Objective
The Cholera‐Hospital‐Based Intervention for 7‐days (CHoBI7) mobile health (mHealth) program delivers mobile messages to diarrhoea patient households promoting water treatment and ...handwashing with soap. The randomised controlled trial (RCT) of the CHoBI7 mHealth program demonstrated this intervention was effective in significantly reducing diarrhoea and stunting amoung young children. The objective of this study was to assess the implementation of the CHoBI7 mHealth program in delivering mHealth messages during this RCT.
Methods
517 diarrhoea patient households with 1777 participants received weekly text, voice and interactive voice response (IVR) messages from the CHoBI7 mHealth program over the 12‐month program period. The program process evaluation indicators were the following: the percentage of CHoBI7 mHealth messages received and fully listened to by program households (program fidelity and dose), and household members reporting receiving and sharing an mHealth message from the program in the past two weeks (program reach).
Results
Ninety two percent of text messages were received by program households. Eighty three percent of voice and 86% of IVR messages sent were fully listened to by at least one household member. Eighty one percent of IVR quiz responses from households were answered correctly. Program households reported receiving a CHoBI7 mHealth message in the past two weeks at 79% of monthly household visits during the 12‐month program. Seventy seven percent of participants reported sharing a program message with a spouse, 55% with a neighbour and 49% with a child during the program period.
Conclusion
There was high fidelity, dose and reach of mobile messages delivered for the CHoBI7 mHealth program. This study presents an approach for process evaluation that can be implemented to evaluate future mHealth programs.
Objectif
Le programme CHoBI7 (Cholera‐Hospital‐Based‐Intervention‐for‐7‐days) de santé mobile (mHealth) délivre des messages mobiles aux ménages avec patients atteints de diarrhée pour promouvoir le traitement de l'eau et le lavage des mains au savon. L'essai contrôlé randomisé (ECR) du programme mHealth CHoBI7 a démontré que cette intervention était efficace pour réduire de manière significative la diarrhée et le retard de croissance chez les jeunes enfants. L'objectif de cette étude était d'évaluer la mise en œuvre du programme CHoBI7 mHealth dans la diffusion des messages mHealth au cours de cet ECR.
Méthodes
517 ménages avec des patients atteints de diarrhée ont reçu chaque semaine des messages SMS, vocaux et de réponse vocale interactive (RVI) du programme mHealth de CHoBI7 pendant les 12 mois du programme. Les indicateurs d'évaluation du processus du programme étaient les suivants: le pourcentage de messages mHealth du programme CHoBI7 reçus (fidélité au programme et dose) et entièrement écoutés par les ménages participant au programme (fidélité au programme et dose) et les bénéficiaires déclarant avoir reçu et partagé un message mHealth du programme (portée du programme) au cours des deux dernières semaines.
Résultats
92% des SMS ont été reçus par les ménages participant au programme. 83% des messages vocaux et 86% des messages RVI envoyés ont été entièrement écoutés par au moins un membre du ménage. 81% des réponses aux quiz RVI des ménages ont été correctement répondues. Les ménages du programme ont déclaré avoir reçu un message CHoBI7 mHealth au cours des deux dernières semaines dans 79% des visites mensuelles des ménages pendant les 12 mois du programme. 77% des participants ont déclaré avoir partagé un message du programme avec un conjoint, 55% avec un voisin et 49% avec un enfant pendant la durée du programme.
Conclusion
La dose et les messages délivrés dans le cadre du programme mHealth de CHoBI7 l’ont été avec une fidélité élevée. Cette étude présente une approche d'évaluation des processus qui peut être mise en œuvre pour évaluer les futurs programmes mHealth.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Arsenic exposure and micronutrient deficiencies may alter immune reactivity to influenza vaccination in pregnant women, transplacental transfer of maternal antibodies to the foetus, and ...maternal and infant acute morbidity.
Objectives
The Pregnancy, Arsenic, and Immune Response (PAIR) Study was designed to assess whether arsenic exposure and micronutrient deficiencies alter maternal and newborn immunity and acute morbidity following maternal seasonal influenza vaccination during pregnancy.
Population
The PAIR Study recruited pregnant women across a large rural study area in Gaibandha District, northern Bangladesh, 2018–2019.
Design
Prospective, longitudinal pregnancy and birth cohort.
Methods
We conducted home visits to enrol pregnant women in the late first or early second trimester (11–17 weeks of gestational age). Women received a quadrivalent seasonal inactivated influenza vaccine at enrolment. Follow‐up included up to 13 visits between enrolment and 3 months postpartum. Arsenic was measured in drinking water and maternal urine. Micronutrient deficiencies were assessed using plasma biomarkers. Vaccine‐specific antibody titres were measured in maternal and infant serum. Weekly telephone surveillance ascertained acute morbidity symptoms in women and infants.
Preliminary Results
We enrolled 784 pregnant women between October 2018 and March 2019. Of 784 women who enrolled, 736 (93.9%) delivered live births and 551 (70.3%) completed follow‐up visits to 3 months postpartum. Arsenic was detected (≥0.02 μg/L) in 99.7% of water specimens collected from participants at enrolment. The medians (interquartile ranges) of water and urinary arsenic at enrolment were 5.1 (0.5, 25.1) μg/L and 33.1 (19.6, 56.5) μg/L, respectively. Water and urinary arsenic were strongly correlated (Spearman's ⍴ = 0.72) among women with water arsenic ≥ median but weakly correlated (⍴ = 0.17) among women with water arsenic < median.
Conclusions
The PAIR Study is well positioned to examine the effects of low‐moderate arsenic exposure and micronutrient deficiencies on immune outcomes in women and infants.
Registration: NCT03930017.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
To assess the association between exposure to prelacteal feeding and infant growth from birth to 3 months of age.
We analyzed data from a cohort of mothers and infants (n = 2569) identified as part ...of ongoing pregnancy and birth surveillance in rural Gaibandha, Bangladesh. Trained interviewers visited women in their households during pregnancy to collect sociodemographic data. Project staff were notified of a birth by telephone and interviewers visited the home within three days post-partum, at one-week, and at three months. At each visit, interviewers collected detailed data on breastfeeding, any foods provided to the infant other than breast milk, and morbidity. Infant weight, length, and mid-upper arm circumference were measured according to standardized protocols at birth and three months of age. For analysis, we defined exposure to prelacteal feeding (PLF) as giving infants any food or liquid other than breastmilk within first 3 days of life. Infant length and weight measurements were used to produce length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z-scores. Stunting, wasting, and underweight were defined as a LAZ, WLZ, or WAZ < –2, respectively. We used multiple linear regression and multiple logistic regression to assess the association between anthropometric indices and PLF practices, controlling for low birthweight, infant sex, infant age, maternal education, maternal age, and wealth.
The prevalence of PLF was 25.2%. The prevalence of stunting, wasting and underweight was 29.0%, 3.8% and 22.3%, respectively. For stunting (adjusted risk ratio (ARR) = 1.02 95% CI: 0.89–1.16) and wasting (ARR = 0.97 95% CI: 0.63–1.50), there were no differences between infants who received PLF and infants who did not receive any PLF. Infants who received PLF tended to have higher risk of underweight (ARR = 1.10 95% CI: 0.95–1.28). For LAZ, WAZ, and WLZ score, no differences were observed in the adjusted analysis between infants who received PLF and those who did not receive any PLF.
There was no association between exposure to PLF and infant growth from birth to 3 months of age. More research is needed to explore the potential effect of PLF on other outcomes.
Bill & Melinda Gates Foundation; Johnson & Johnson; UBS Optimus Foundation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Our objective was to assess changes in prelacteal feeding practices in rural Bangladesh over a 15-year period, from ∼2004 to ∼2019, and to identify household, maternal, and infant characteristics ...associated with that trend.
The analysis used data from 21,804 infants enrolled in a cluster-randomized controlled trial of newborn vitamin A supplementation from 2004–2006, and from 4631 infants enrolled in a cluster-randomized controlled trial of a digital health intervention from 2018–2019. In both studies, trained field workers collected data on household socioeconomic status and maternal demographic characteristics at the time of enrollment. Upon receiving notification of an infant’s birth, field workers visited the home as soon as possible, collecting detailed data on breastfeeding initiation and any foods or liquids other than breast milk provided to the infant. Prelacteal feeding was defined as giving infants any food or liquid other than breast milk within first 3 days of life. We used bivariate and multivariate logistic regression analyses to examine the association between different household, maternal, and infant characteristics and prelacteal feeding. We then applied a regression decomposition method to understand the factors associated with the changing prevalence of prelacteal feeding over time.
The prevalence of prelacteal feeding was 88.0% during the period of 2004–2006. Among women practicing prelacteal feeding, sugar/sugar candy water was the most commonly fed prelacteal (41.2%), followed by animal milk (40.0%), honey (35.4%), and drops (11.8%). By 2018–2019, the prevalence of prelacteal feeding had declined to 24.7%. Most frequently consumed prelacteals were most commonly sugar/sugar candy water (20.0%), honey (20.0%), animal milk (19.7%), and drops (14.3%). Final analysis will include examination of the changing factors associated with this decline including rising maternal education, improvements in socioeconomic status, and exposure to media.
The prevalence of prelacteal feeding has dropped considerably in rural Bangladesh since 2004.
The Bill and Melinda Gates Foundation; United States Agency for International Development; Sight and Life.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We assessed micronutrient status in young rural Bangladeshi adolescents to determine prevalence of deficiency by sex, age, season and dietary pattern.
In a birth cohort of >30,000 youth in whom data ...on health, development, and nutritional status was collected in 2015–2017, venous blood was drawn from a ∼3% subsample (n = 991, 9–13 years old). Participants’ mothers had been in a cluster-randomized, placebo-controlled trial of daily antenatal beta-carotene or vitamin A supplementation in 2001–2007. Hemoglobin (Hb) was obtained at blood draw; plasma ferritin, folate, cobalamin (B12), homocysteine (Hcy), thyroglobulin (Tg), and C-reactive protein (CRP) were measured by chemiluminescent immunoassay, 25-hydroxyvitamin D 25(OH)D by commercial immunoassay, and zinc by atomic absorption spectrometry.
Participants were short (height-for-age Z-score –1.59 ± 0.93 in boys, –1.65 ± 0.98 in girls) and thin (BMI-for-age Z-score –1.49 ± 1.06 in boys, –1.28 ± 1.08 in girls). Anemia (Hb <120 g/L, 11.4%) was common but iron deficiency (ferritin <15 μg/L, 0.5%) was not. Folate (<6.8 nmol/L, 3.3%) and vitamin B12 (<150 pmol/L, 5.2%) deficiencies, elevated Hcy (>18 μmol/L, 0.8%) and inflammation (CRP >5 mg/L, 3.3%) were uncommon. However, deficiencies of vitamin D (25(OH)D < 50 nmol/L, 43.0%), iodine (Tg > 40 μg/L, 21.9%), and zinc (<8.6 μmol/L, 18.8%) were prevalent. Only vitamin D deficiency was more prevalent in girls than boys (54.0% versus 31.4%, P < 0.0001), doubling in girls from 32.5% at 10 to 69.7% at 13 years of age. Vitamin D deficiency was highest in winter and zinc deficiency highest during the monsoon. In preliminary analyses, micronutrient deficiencies were not significantly associated with dietary intake patterns derived from three 7-day food frequencies collected over ∼1 year.
Young adolescents in rural northern Bangladesh experienced anemia and vitamin D, iodine and zinc deficiencies; however, iron, folate, and B12 deficiencies, hyperhomocysteinemia, and inflammation were uncommon. Further resolution of dietary data and exploration of other contextual features may reveal specific risk factors for micronutrient deficiencies, informing our understanding of adolescent nutritional status in this setting.
The Bill and Melinda Gates Foundation, Sight and Life.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We assessed micronutrient status in young rural Bangladeshi adolescents to determine prevalence of deficiency by sex, age, season and dietary pattern.
In a birth cohort of >30,000 youth in whom data ...on health, development, and nutritional status was collected in 2015–2017, venous blood was drawn from a ∼3% subsample (n = 991, 9–13 years old). Participants’ mothers had been in a cluster-randomized, placebo-controlled trial of daily antenatal beta-carotene or vitamin A supplementation in 2001–2007. Hemoglobin (Hb) was obtained at blood draw; plasma ferritin, folate, cobalamin (B12), homocysteine (Hcy), thyroglobulin (Tg), and C-reactive protein (CRP) were measured by chemiluminescent immunoassay, 25-hydroxyvitamin D 25(OH)D by commercial immunoassay, and zinc by atomic absorption spectrometry.
Participants were short (height-for-age Z-score -1.59 ± 0.93 in boys, -1.65 ± 0.98 in girls) and thin (BMI-for-age Z-score -1.49 ± 1.06 in boys, -1.28 ± 1.08 in girls). Anemia (Hb < 120 g/L, 11.4%) was common but iron deficiency (ferritin < 15 μg/L, 0.5%) was not. Folate (< 6.8 nmol/L, 3.3%) and vitamin B12 (<150 pmol/L, 5.2%) deficiencies, elevated Hcy (>18 μmol/L, 0.8%) and inflammation (CRP >5 mg/L, 3.3%) were uncommon. However, deficiencies of vitamin D (25(OH) D < 50 nmol/L, 43.0%), iodine (Tg > 40 μg/L, 21.9%), and zinc (< 8.6 μmol/L, 18.8%) were prevalent. Only vitamin D deficiency was more prevalent in girls than boys (54.0% versus 31.4%, P < 0.0001), doubling in girls from 32.5% at 10 to 69.7% at 13 years of age. Vitamin D deficiency was highest in winter and zinc deficiency highest during the monsoon. In preliminary analyses, micronutrient deficiencies were not significantly associated with dietary intake patterns derived from three 7-day food frequencies collected over ∼1 year.
Young adolescents in rural northern Bangladesh experienced anemia and vitamin D, iodine and zinc deficiencies; however, iron, folate, and B12 deficiencies, hyperhomocysteinemia, and inflammation were uncommon. Further resolution of dietary data and exploration of other contextual features may reveal specific risk factors for micronutrient deficiencies, informing our understanding of adolescent nutritional status in this setting.
The Bill and Melinda Gates Foundation, Sight and Life.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
To assess the impact of daily egg supplementation on infant growth from 6–12 months of age in Bangladesh.
A cluster randomized controlled trial was conducted in rural Bangladesh to test the effect of ...daily egg supplementation and nutrition education versus nutrition education alone on linear growth and stunting prevalence among infants. Infants were enrolled at 3 months of age and assigned to a trial arm based on their geographic sector of residence. Households were visited weekly to distribute eggs and monitor compliance starting at 6 months of age. Length, weight, head circumference, and mid upper arm circumference were measured at 6, 9, and 12 months, as well as dietary intake from home foods in the last 24 hours. Analyses were conducted on an intention-to-treat basis. Linear regression models were developed for continuous outcomes. For dichotomous outcomes, prevalence ratios were estimated using log-binomial regression models. Generalized estimating equations were used with all models to account for clustering. Each model was adjusted for the baseline measure of the outcome variable.
Overall, 909 infants were enrolled in the treatment arm from 142 clusters and 842 infants in the control arm from 140 clusters. Prevalence of stunting at baseline was 19.4%, wasting was 6.7%, and underweight was 18.1%. After 6 months of supplementation, the intervention had no effect on mean length-for-age z-scores (β = 0.05, 95% CI: –0.12, 0.23) or prevalence of stunting (PR = 1.00, 95% CI: 0.90, 1.10). Infants in the egg arm had significantly higher mean weight-for-length z-scores (β = 0.11, 95% CI: 0.04, 0.18) and weight-for-age z-scores (β = 0.08, 95% CI: 0.03, 0.12), adjusting for baseline measures of the outcomes. Our presented results will include findings from mixed-effects regression analyses assessing the effect of the intervention on growth rate.
The provision of a daily egg for 6 months to infants in rural Bangladesh had an effect on ponderal but not linear growth.
Bill and Melinda Gates Foundation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Intake of high-quality protein may be insufficient to support growth in the context of high enteric pathogen carriage and environmental enteric dysfunction. Our objective was to test whether ...supplemental protein, with or without presumptive treatment for enteric pathogens, would improve infant growth from 6–12 months of age.
We conducted a 2 × 4 factorial cluster-randomized trial in rural Bangladesh. The first factor was azithromycin treatment (10 mg/kg * 3 days) or placebo at 6 & 9 months of age. The second factor, delivered from 6–12 months of age, consisted of: supplemental protein as daily porridge (125 kcal/d, with 10 g protein/day as egg white powder) or a daily egg; an isocaloric daily porridge; or nutrition education alone. The present aim tested the impact of the protein-rich porridge, with or without azithromycin treatment. All infants born in the study area over a 9-mo period were eligible and consented at ∼3 mo of age. Trained field workers measured infant size at 6, 9, and 12 mo of age using standardized protocols. We used linear regression with generalized estimating equations to test the interventions’ impact on anthropometric indices, respectively, at 12 mo of age, controlling for baseline measures. Analysis was intention-to-treat.
Overall, 2205 infants were enrolled from 282 clusters and exposed to both nutrition (1074 in protein arm from 140 clusters; 1074 in the isocaloric arm from 142 clusters) and presumptive treatment interventions. At baseline, 18.7%, 16.9%, and 6.4% of infants were stunted, underweight, and wasted, respectively. There was no statistical interaction between protein supplementation and azithromycin treatment for any of the anthropometric indices, so groups were combined. In the analysis of main effects, added protein had no impact on mean length-for-age (β = 0.01; 95% CI: –0.06, 0.08), weight-for-age (β = –0.002; 95% CI: –0.06, 0.05), or weight-for-length (β = –0.04; 95% CI: –0.12, 0.05) Z-scores at 12 mo of age.
Supplemental protein from 6–12 mo of age had no effect on mean linear or ponderal growth measured at 12 mo of age, irrespective of presumptive treatment for enteric pathogens with azithromycin.
The Bill and Melinda Gates Foundation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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